ANNEX I

SUMMARY OF PRODUCT CHARACTERISTICS

1 1. NAME OF THE MEDICINAL PRODUCT

Xultophy 100 units/mL + 3.6 mg/mL solution for injection.

2. QUALITATIVE AND QUANTITATIVE COMPOSITION

1 mL solution contains 100 units insulin degludec* and 3.6 mg liraglutide*.

*Produced in Saccharomyces cerevisiae by recombinant DNA technology.

One pre-filled pen contains 3 mL equivalent to 300 units insulin degludec and 10.8 mg liraglutide.

One dose step contains 1 unit of insulin degludec and 0.036 mg of liraglutide.

For the full list of excipients, see section 6.1.

3. PHARMACEUTICAL FORM

Solution for injection.

Clear, colourless, isotonic solution.

4. CLINICAL PARTICULARS

4.1 Therapeutic indications

Xultophy is indicated for the treatment of adults with insufficiently controlled type 2 diabetes mellitus to improve glycaemic control as an adjunct to diet and exercise in addition to other oral medicinal products for the treatment of diabetes. For study results with respect to combinations, effects on glycaemic control, and the populations studied, see sections 4.4, 4.5 and 5.1.

4.2 Posology and method of administration

Posology

Xultophy is given once daily by subcutaneous administration. Xultophy can be administered at any time of the day, preferably at the same time of the day.

Xultophy is to be dosed in accordance with the individual patient’s needs. It is recommended to optimise glycaemic control via dose adjustment based on fasting plasma glucose.

Adjustment of dose may be necessary if patients undertake increased physical activity, change their usual diet or during concomitant illness.

Patients who forget a dose are advised to take it upon discovery and then resume their usual once-daily dosing schedule. A minimum of 8 hours between injections should always be ensured. This also applies when administration at the same time of the day is not possible.

Xultophy is administered as dose steps. One dose step contains 1 unit of insulin degludec and 0.036 mg of liraglutide. The pre-filled pen can provide from 1 up to 50 dose steps in one injection in increments of one dose step. The maximum daily dose of Xultophy is 50 dose steps (50 units insulin degludec and 1.8 mg liraglutide). The dose counter on the pen shows the number of dose steps.

Add-on to oral glucose-lowering medicinal products

2 The recommended starting dose of Xultophy is 10 dose steps (10 units insulin degludec and 0.36 mg liraglutide).

Xultophy can be added to existing oral antidiabetic treatment. When Xultophy is added to sulfonylurea therapy, a reduction in the dose of sulfonylurea should be considered (see section 4.4).

Transfer from GLP-1 receptor agonist Therapy with GLP-1 receptor agonists should be discontinued prior to initiation of Xultophy. When transferring from a GLP-1 receptor agonist, the recommended starting dose of Xultophy is 16 dose steps (16 units insulin degludec and 0.6 mg liraglutide) (see section 5.1). The recommended starting dose should not be exceeded. If transferring from a long-acting GLP-1 receptor agonist (e.g. once- weekly dosing), the prolonged action should be considered. Treatment with Xultophy should be initiated at the moment the next dose of the long-acting GLP-1 receptor agonist would have been taken. Close glucose monitoring is recommended during the transfer and in the following weeks.

Transfer from any insulin regimen that includes a basal insulin component Therapy with other insulin regimens should be discontinued prior to initiation of Xultophy. When transferring from any other insulin therapy that includes a basal insulin component, the recommended starting dose of Xultophy is 16 dose steps (16 units insulin degludec and 0.6 mg liraglutide) (see section 4.4 and 5.1). The recommended starting dose should not be exceeded, but may be reduced to avoid hypoglycaemia in selected cases. Close glucose monitoring is recommended during the transfer and in the following weeks.

Special populations

Elderly patients (≥65 years old) Xultophy can be used in elderly patients. Glucose monitoring is to be intensified and the dose adjusted on an individual basis.

Renal impairment When Xultophy is used in patients with mild, moderate or severe renal impairment, glucose monitoring is to be intensified and the dose adjusted on an individual basis. Xultophy cannot be recommended for use in patients with end-stage renal disease (see sections 5.1 and 5.2).

Hepatic impairment Xultophy can be used in patients with mild or moderate hepatic impairment. Glucose monitoring is to be intensified and the dose adjusted on an individual basis. Due to the liraglutide component, Xultophy is not recommended for use in patients with severe hepatic impairment (see section 5.2).

Paediatric population There is no relevant use of Xultophy in the paediatric population.

Method of administration

Xultophy is for subcutaneous use only. Xultophy must not be administered intravenously or intramuscularly.

Xultophy is administered subcutaneously by injection in the thigh, the upper arm or the abdomen. Injection sites should always be rotated within the same region in order to reduce the risk of lipodystrophy and cutaneous amyloidosis (see sections 4.4 and 4.8). For further instructions on administration, see section 6.6.

Xultophy must not be drawn from the cartridge of the pre-filled pen into a syringe (see section 4.4).

Patients should be instructed to always use a new needle. The re-use of insulin pen needles increases the risk of blocked needles, which may cause under- or overdosing. In the event of blocked needles,

3 patients must follow the instructions described in the instructions for use accompanying the package leaflet (see section 6.6).

4.3 Contraindications

Hypersensitivity to either or both active substances or to any of the excipients listed in section 6.1.

4.4 Special warnings and precautions for use

Xultophy should not be used in patients with type 1 diabetes mellitus or for the treatment of diabetic ketoacidosis.

Hypoglycaemia

Hypoglycaemia may occur if the dose of Xultophy is higher than required. Omission of a meal or unplanned strenuous physical exercise may lead to hypoglycaemia. In combination with sulfonylurea, the risk of hypoglycaemia may be lowered by a reduction in the dose of sulfonylurea. Concomitant diseases in the kidney, liver or diseases affecting the adrenal, pituitary or thyroid gland may require changes of the Xultophy dose. Patients whose blood glucose control is greatly improved (e.g. by intensified therapy) may experience a change in their usual warning symptoms of hypoglycaemia and must be advised accordingly. Usual warning symptoms (see section 4.8) of hypoglycaemia may disappear in patients with long-standing diabetes. The prolonged effect of Xultophy may delay recovery from hypoglycaemia.

Hyperglycaemia

Inadequate dosing and/or discontinuation of antidiabetic treatment may lead to hyperglycaemia and potentially to hyperosmolar coma. In case of discontinuation of Xultophy, ensure that instruction for initiation of alternative antidiabetic treatment is followed. Furthermore, concomitant illness, especially infections, may lead to hyperglycaemia and thereby cause an increased requirement for antidiabetic treatment. Usually, the first symptoms of hyperglycaemia develop gradually over a period of hours or days. They include thirst, increased frequency of urination, nausea, vomiting, drowsiness, flushed dry skin, dry mouth, and loss of appetite as well as acetone odour of breath. Administration of rapid-acting insulin should be considered in situations of severe hyperglycaemia. Untreated hyperglycaemic events eventually lead to hyperosmolar coma/diabetic ketoacidosis, which is potentially lethal.

Skin and subcutaneous tissue disorders

Patients must be instructed to perform continuous rotation of the injection site to reduce the risk of developing lipodystrophy and cutaneous amyloidosis. There is a potential risk of delayed insulin absorption and worsened glycaemic control following insulin injections at sites with these reactions. A sudden change in the injection site to an unaffected area has been reported to result in hypoglycaemia. Blood glucose monitoring is recommended after the change in the injection site from an affected to an unaffected area, and dose adjustment of antidiabetic medications may be considered.

Combination of pioglitazone and insulin medicinal products

Cases of cardiac failure have been reported when pioglitazone was used in combination with insulin medicinal products, especially in patients with risk factors for development of cardiac failure. This should be kept in mind if treatment with the combination of pioglitazone and Xultophy is considered. If the combination is used, patients should be observed for signs and symptoms of heart failure, weight gain and oedema. Pioglitazone should be discontinued if any deterioration in cardiac symptoms occurs.

Eye disorder

4 Intensification of therapy with insulin, a component of Xultophy, with abrupt improvement in glycaemic control may be associated with temporary worsening of diabetic retinopathy, while long- term improved glycaemic control decreases the risk of progression of diabetic retinopathy.

Antibody formation

Administration of Xultophy may cause formation of antibodies against insulin degludec and/or liraglutide. In rare cases, the presence of such antibodies may necessitate adjustment of the Xultophy dose in order to correct a tendency to hyper- or hypoglycaemia. Very few patients developed insulin degludec specific antibodies, antibodies cross-reacting to human insulin or anti-liraglutide antibodies following treatment with Xultophy. Antibody formation has not been associated with reduced efficacy of Xultophy.

Acute pancreatitis

Acute pancreatitis has been observed with the use of GLP-1 receptor agonists, including liraglutide. Patients should be informed of the characteristic symptoms of acute pancreatitis. If pancreatitis is suspected, Xultophy should be discontinued; if acute pancreatitis is confirmed, Xultophy should not be restarted.

Thyroid adverse events

Thyroid adverse events, such as goitre have been reported in clinical trials with GLP-1 receptor agonists including liraglutide, and in particular in patients with pre-existing thyroid disease. Xultophy should therefore be used with caution in these patients.

Inflammatory bowel disease and diabetic gastroparesis

There is no experience with Xultophy in patients with inflammatory bowel disease and diabetic gastroparesis. Xultophy is therefore not recommended in these patients.

Dehydration

Signs and symptoms of dehydration, including renal impairment and acute renal failure have been reported in clinical trials with GLP-1 receptor agonists including liraglutide, a component of Xultophy. Patients treated with Xultophy should be advised of the potential risk of dehydration in relation to gastrointestinal side effects and take precautions to avoid fluid depletion.

Avoidance of medication errors

Patients must be instructed to always check the pen label before each injection to avoid accidental mix-ups between Xultophy and other injectable diabetes medicinal products.

Patients must visually verify the dialled units on the dose counter of the pen. Therefore, the requirement for patients to self-inject is that they can read the dose counter on the pen. Patients who are blind or have poor vision must be instructed to always get help/assistance from another person who has good vision and is trained in using the insulin device.

To avoid dosing errors and potential overdose, patients and healthcare professionals should never use a syringe to draw the medicinal product from the cartridge in the pre-filled pen.

In the event of blocked needles, patients must follow the instructions described in the instructions for use accompanying the package leaflet (see section 6.6).

Populations not studied

Transfer to Xultophy from doses of basal insulin <20 and >50 units has not been studied.

5

There is no therapeutic experience in patients with congestive heart failure New York Heart Association (NYHA) class IV and Xultophy is therefore not recommended for use in these patients.

Excipients

Xultophy contains less than 1 mmol sodium (23 mg) per dose, therefore the medicinal product is essentially ‘sodium-free’.

Traceability In order to improve the traceability of biological medicinal products, the name and the batch number of the administered product should be clearly recorded.

4.5 Interaction with other medicinal products and other forms of interaction

Pharmacodynamic interactions

Interaction studies with Xultophy have not been performed. A number of substances affect glucose metabolism and may require dose adjustment of Xultophy.

The following substances may reduce the Xultophy requirement: Antidiabetic medicinal products, monoamine oxidase inhibitors (MAOI), beta-blockers, angiotensin converting enzyme (ACE) inhibitors, salicylates, anabolic steroids and sulfonamides.

The following substances may increase the Xultophy requirement: Oral contraceptives, thiazides, glucocorticoids, thyroid hormones, sympathomimetics, growth hormones and danazol.

Beta-blockers may mask the symptoms of hypoglycaemia. Octreotide/lanreotide may either increase or decrease the Xultophy requirement. Alcohol may intensify or reduce the hypoglycaemic effect of Xultophy.

Pharmacokinetic interactions

In vitro data suggest that the potential for pharmacokinetic drug interactions related to CYP interaction and protein binding is low for both liraglutide and insulin degludec.

The small delay of gastric emptying with liraglutide may influence absorption of concomitantly administered oral medicinal products. Interaction studies did not show any clinically relevant delay of absorption.

Warfarin and other coumarin derivatives No interaction study has been performed. A clinically relevant interaction with active substances with poor solubility or with narrow therapeutic index such as warfarin cannot be excluded. Upon initiation of Xultophy treatment in patients on warfarin or other coumarin derivatives more frequent monitoring of INR (International Normalised Ratio) is recommended.

Paracetamol Liraglutide did not change the overall exposure of paracetamol following a single dose of 1,000 mg. Paracetamol Cmax was decreased by 31% and median tmax was delayed up to 15 min. No dose adjustment for concomitant use of paracetamol is required.

Atorvastatin Liraglutide did not change the overall exposure of atorvastatin to a clinical relevant degree following single dose administration of atorvastatin 40 mg. Therefore, no dose adjustment of atorvastatin is required when given with liraglutide. Atorvastatin Cmax was decreased by 38% and median tmax was delayed from 1 h to 3 h with liraglutide.

6

Griseofulvin Liraglutide did not change the overall exposure of griseofulvin following administration of a single dose of griseofulvin 500 mg. Griseofulvin Cmax increased by 37% while median tmax did not change. Dose adjustments of griseofulvin and other compounds with low solubility and high permeability are not required.

Digoxin A single dose administration of digoxin 1 mg with liraglutide resulted in a reduction of digoxin AUC by 16%; Cmax decreased by 31%. Digoxin median time to maximum concentration (tmax) was delayed from 1 h to 1.5 h. No dose adjustment of digoxin is required based on these results.

Lisinopril A single dose administration of lisinopril 20 mg with liraglutide resulted in a reduction of lisinopril AUC by 15%; Cmax decreased by 27%. Lisinopril median tmax was delayed from 6 h to 8 h with liraglutide. No dose adjustment of lisinopril is required based on these results.

Oral contraceptives Liraglutide lowered ethinylestradiol and levonorgestrel Cmax by 12 and 13%, respectively, following administration of a single dose of an oral contraceptive product. Tmax was delayed by 1.5 h with liraglutide for both compounds. There was no clinically relevant effect on the overall exposure of either ethinylestradiol or levonorgestrel. The contraceptive effect is therefore anticipated to be unaffected when co-administered with liraglutide.

4.6 Fertility, pregnancy and lactation

Pregnancy

There is no clinical experience with the use of Xultophy, insulin degludec or liraglutide in pregnant women. If a patient wishes to become pregnant, or pregnancy occurs, treatment with Xultophy should be discontinued.

Animal reproduction studies with insulin degludec have not revealed any differences between insulin degludec and human insulin regarding embryotoxicity and teratogenicity. Animal studies with liraglutide have shown reproductive toxicity, see section 5.3. The potential risk for humans is unknown.

Breast-feeding

There is no clinical experience with the use of Xultophy during breast-feeding. It is not known whether insulin degludec or liraglutide is excreted in human milk. Because of lack of experience, Xultophy should not be used during breast-feeding. In rats, insulin degludec was secreted in milk; the concentration in milk was lower than in plasma. Animal studies have shown that the transfer of liraglutide and metabolites of close structural relationship into milk was low. Non-clinical studies with liraglutide have shown a treatment-related reduction of neonatal growth in suckling rat pups (see section 5.3).

Fertility

There is no clinical experience with Xultophy in relation to fertility. Animal reproduction studies with insulin degludec have not revealed any adverse effects on fertility. Apart from a slight decrease in the number of live implants, animal studies with liraglutide did not indicate harmful effects with respect to fertility.

4.7 Effects on ability to drive and use machines

The patient’s ability to concentrate and react may be impaired as a result of hypoglycaemia. This may

7 constitute a risk in situations where these abilities are of special importance (e.g. driving a car or using machines).

Patients must be advised to take precautions to avoid hypoglycaemia while driving. This is particularly important in those who have reduced or absent awareness of the warning signs of hypoglycaemia or have frequent episodes of hypoglycaemia. The advisability of driving should be considered in these circumstances.

4.8 Undesirable effects

Summary of the safety profile

The Xultophy clinical development programme included approximately 1,900 patients treated with Xultophy.

The most frequently reported adverse reactions during treatment with Xultophy were hypoglycaemia and gastrointestinal adverse reactions (see section ‘Description of selected adverse reactions’ below).

Tabulated list of adverse reactions

Adverse reactions associated with Xultophy are given below, listed by system organ class and frequency. Frequency categories are defined as: Very common (≥1/10); common (≥1/100 to <1/10); uncommon (≥1/1,000 to <1/100); rare (≥1/10,000 to <1/1,000); very rare (<1/10,000) and not known (cannot be estimated from the available data).

Table 1 Adverse reactions reported in phase 3 controlled studies MedDRA System organ class Frequency Adverse reaction Immune system disorders Uncommon Urticaria Uncommon Hypersensitivity Unknown Anaphylactic reaction Metabolism and nutrition Very common Hypoglycaemia disorders Common Decreased appetite Uncommon Dehydration Gastrointestinal disorders Common Nausea, diarrhoea, vomiting, constipation, dyspepsia, gastritis, abdominal pain, gastroesophageal reflux disease, abdominal distension Uncommon Eructation, flatulence Unknown Pancreatitis (including necrotising pancreatitis ) Hepatobiliary disorders Uncommon Cholelithiasis Uncommon Cholecystitis Skin and subcutaneous tissue Uncommon Rash disorders Uncommon Pruritus Uncommon Lipodystrophy acquired Not known Cutaneous amyloidosis† General disorders and Common Injection site reaction administration site condition Unknown Peripheral oedema Investigation Common Increased lipase Common Increased amylase Uncommon Increased heart rate † ADR from postmarketing sources.

Description of selected adverse reactions

Hypoglycaemia

8 Hypoglycaemia may occur if the Xultophy dose is higher than required. Severe hypoglycaemia may lead to unconsciousness and/or convulsions and may result in temporary or permanent impairment of brain function or even death. The symptoms of hypoglycaemia usually occur suddenly. They may include cold sweats, cool pale skin, fatigue, nervousness or tremor, anxiousness, unusual tiredness or weakness, confusion, difficulty in concentration, drowsiness, excessive hunger, vision changes, headache, nausea and palpitation. For frequencies of hypoglycaemia, please see section 5.1.

Allergic reactions Allergic reactions (manifested with signs and symptoms such as urticaria (0.3% of patients treated with Xultophy), rash (0.7%), pruritus (0.5%) and/or swelling of the face (0.2%)) have been reported for Xultophy. Few cases of anaphylactic reactions with additional symptoms such as hypotension, palpitations, dyspnoea, and oedema have been reported during marketed use of liraglutide. Anaphylactic reactions may potentially be life threatening.

Gastrointestinal adverse reactions Gastrointestinal adverse reactions may occur more frequently at the beginning of Xultophy therapy and usually diminish within a few days or weeks on continued treatment. Nausea was reported in 7.8% of patients and was transient in nature for most patients. The proportion of patients reporting nausea per week at any point during treatment was below 4%. Diarrhoea and vomiting were reported in 7.5% and 3.9% of patients, respectively. The frequency of nausea and diarrhoea was ‘Common’ for Xultophy and ‘Very common’ for liraglutide. In addition, constipation, dyspepsia, gastritis, abdominal pain, gastroesophageal reflux disease, abdominal distension, eructation, flatulence and decreased appetite have been reported in up to 3.6% of patients treated with Xultophy.

Injection site reactions Injection site reactions (including injection site haematoma, pain, haemmorrhage, erythema, nodules, swelling, discolouration, pruritus, warmth and injection site mass) have been reported in 2.6% of patients treated with Xultophy. These reactions were usually mild and transitory and they normally disappear during continued treatment.

Skin and subcutaneous tissue disorders Lipodystrophy (including lipohypertrophy, lipoatrophy) and cutaneous amyloidosis may occur at the injection site and delay local insulin absorption. Continuous rotation of the injection site within the given injection area may help to reduce or prevent these reactions (see section 4.4).

Increased heart rate Mean increase in heart rate from baseline of 2 to 3 beats per minute has been observed in clinical trials with Xultophy. In the LEADER trial, no long-term clinical impact of increased heart rate on the risk of cardiovascular events was observed with liraglutide (a component of Xultophy) (see section 5.1).

Reporting of suspected adverse reactions

Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the national reporting system listed in Appendix V.

4.9 Overdose

Limited data are available with regard to overdose of Xultophy.

Hypoglycaemia may develop if a patient is dosed with more Xultophy than required:

• Mild hypoglycaemic episodes can be treated by oral administration of glucose or other products containing sugar. It is therefore recommended that the patient always carries sugar-containing products • Severe hypoglycaemic episodes, where the patient is not able to treat himself, can be treated

9 with glucagon (0.5 to 1 mg) given intramuscularly or subcutaneously by a trained person, or with glucose given intravenously by a healthcare professional. Glucose must be given intravenously if the patient does not respond to glucagon within 10 to 15 minutes. Upon regaining consciousness, administration of oral carbohydrates is recommended for the patient in order to prevent a relapse.

5. PHARMACOLOGICAL PROPERTIES

5.1 Pharmacodynamic properties

Pharmacotherapeutic group: Drugs used in diabetes. Insulins and analogues for injection, long-acting. ATC code: A10AE56

Mechanism of action

Xultophy is a combination product consisting of insulin degludec and liraglutide having complementary mechanisms of action to improve glycaemic control.

Insulin degludec is a basal insulin that forms soluble multi-hexamers upon subcutaneous injection, resulting in a depot from which insulin degludec is continuously and slowly absorbed into the circulation leading to a flat and stable glucose-lowering effect of insulin degludec with a low day-to- day variability in insulin action.

Insulin degludec binds specifically to the human insulin receptor and results in the same pharmacological effects as human insulin.

The blood glucose-lowering effect of insulin degludec is due to the facilitated uptake of glucose following the binding of insulin to receptors on muscle and fat cells and to the simultaneous inhibition of glucose output from the liver.

Liraglutide is a Glucagon-Like Peptide-1 (GLP-1) analogue with 97% sequence homology to human GLP-1 that binds to and activates the GLP-1 receptor (GLP-1R). Following subcutaneous administration, the protracted action profile is based on three mechanisms: self-association, which results in slow absorption; binding to albumin; and higher enzymatic stability towards the dipeptidyl peptidase IV (DPP-IV) and neutral endopeptidase (NEP) enzymes, resulting in a long plasma half-life.

Liraglutide action is mediated via a specific interaction with GLP-1 receptors and improves glycaemic control by lowering fasting and postprandial blood glucose. Liraglutide stimulates insulin secretion and lowers inappropriately high glucagon secretion in a glucose-dependent manner. Thus, when blood glucose is high, insulin secretion is stimulated and glucagon secretion is inhibited. Conversely, during hypoglycaemia liraglutide diminishes insulin secretion and does not impair glucagon secretion. The mechanism of blood glucose-lowering also involves a minor delay in gastric emptying.

Liraglutide reduces body weight and body fat mass through mechanisms involving reduced hunger and lowered energy intake.

GLP-1 is a physiological regulator of appetite and food intake, but the exact mechanism of action is not entirely clear. In animal studies, peripheral administration of liraglutide led to uptake in specific brain regions involved in regulation of appetite, where liraglutide, via specific activation of the GLP- 1R, increased key satiety and decreased key hunger signals, thereby leading to lower body weight.

GLP-1 receptors are also expressed in specific locations in the heart, vasculature, immune system, and kidneys. In mouse models of atherosclerosis, liraglutide prevented aortic plaque progression and reduced inflammation in the plaque. In addition, liraglutide had a beneficial effect on plasma lipids. Liraglutide did not reduce the plaque size of already established plaques.

10 Pharmacodynamic effects

Xultophy has a stable pharmacodynamic profile with a duration of action reflecting the combination of the individual action profiles of insulin degludec and liraglutide that allows for administration of Xultophy once daily at any time of the day with or without meals. Xultophy improves glycaemic control through the sustained lowering of fasting plasma glucose levels and postprandial glucose levels after all meals.

Postprandial glucose reduction was confirmed in a 4 hour standardised meal test substudy in patients uncontrolled on metformin alone or in combination with pioglitazone. Xultophy decreased the postprandial plasma glucose excursion (mean over 4 hours) significantly more than insulin degludec. The results were similar for Xultophy and liraglutide.

Clinical efficacy and safety

The safety and efficacy of Xultophy were evaluated in seven randomised, controlled, parallel group phase 3 trials in different populations of subjects with type 2 diabetes defined by previous antidiabetes treatment. Comparator treatments comprised basal insulin, GLP-1 RA therapy, placebo and a basal bolus regimen. The trials were of 26 weeks duration randomising between 199 and 833 patients to Xultophy. One study was further extended to 52 weeks. In all trials, the starting dose was given according to label and a twice-weekly titration regimen for Xultophy was used (see Table 2). The same titration algorithm was applied for basal insulin comparators. In six studies, Xultophy produced clinically and statistically significant improvements in glycaemic control versus comparators as measured by glycated haemaglobin A1c (HbA1c), whereas one study demonstrated a similar reduction of HbA1c in both treatment arms.

Table 2 Titration of Xultophy Pre-breakfast plasma glucose* Dose adjustment (twice weekly) mmol/L mg/dL Xultophy (dose steps) <4.0 <72 -2 4.0–5.0 72–90 0 >5.0 >90 +2 *Self-measured plasma glucose. In the trial investigating Xultophy as add on to sulfonylurea the target was 4.0-6.0 mmol/L

• Glycaemic control

Add-on to oral glucose-lowering medicinal products Adding Xultophy to metformin alone or in combination with pioglitazone in a 26-week randomised, controlled, open-label trial resulted in 60.4% of patients treated with Xultophy reaching a target of HbA1c <7% without confirmed hypoglycaemic episodes after 26 weeks of treatment. The proportion was significantly larger than observed with insulin degludec (40.9%, odds ratio 2.28, p <0.0001) and similar to that observed with liraglutide (57.7%, odds ratio 1.13, p=0.3184). The key results of the trial are listed in Figure 1 and Table 3.

Rates of confirmed hypoglycaemia were lower with Xultophy than with insulin degludec irrespective of the glycaemic control, see Figure 1. The rate per patient year of exposure (percentage of patients) of severe hypoglycaemia defined as an episode requiring assistance of another person was 0.01 (2 patients out of 825) for Xultophy, 0.01 (2 patients out of 412) for insulin degludec and 0.00 (0 patients out of 412) for liraglutide. The rate of nocturnal hypoglycaemic events was similar with Xultophy and insulin degludec treatment.

Patients treated with Xultophy overall experienced less gastrointestinal side effects than patients treated with liraglutide. This might be due to the slower increase in the dose of the liraglutide component during treatment initiation when using Xultophy as compared to using liraglutide alone.

The efficacy and safety of Xultophy were sustained up to 52 weeks of treatment. The reduction in HbA1c from baseline to 52 weeks was 1.84% with Xultophy with an estimated treatment difference of

11 -0.65% compared to liraglutide (p<0.0001) and -0.46% compared to insulin degludec (p<0.0001). Body weight was reduced by 0.4 kg with an estimated treatment difference between Xultophy and insulin degludec of -2.80 kg (p<0.0001), and the rate of confirmed hypoglycaemia remained 1.8 events per patient year of exposure maintaining a significant reduction in overall risk of confirmed hypoglycaemia compared to insulin degludec.

IDegLira IDeg IDegLira obs. rate

Lira IDegLira IDeg IDeg obs. rate HbA1c (%)

Time since Randomisation (Week) Rate hypoglycaemia of (events PYE) per HbA1c (%) at end of treatment The curves are mean hypo rates from a negative binomial model with unique treatment trajectories and the symbols are observed hypo rates vs. mean HbA1c by quartiles. IDegLira=Xultophy, IDeg=insulin degludec, Lira=liraglutide, obs. rate=observed rate, PYE=patient year of exposure

Figure 1 Mean HbA1c (%) by treatment week (left) and rate of confirmed hypoglycaemia per patient year of exposure vs mean HbA1c (%) (right) in patients with type 2 diabetes mellitus inadequately controlled on metformin alone or in combination with pioglitazone

Xultophy as add-on to sulfonylurea alone or in combination with metformin were studied in a 26-week randomised, placebo-controlled, double-blind trial. The key results of the trial are listed in Figure 2 and Table 3.

IDegLira Placebo

HbA1c (%)

Time since Randomisation (Week) IDegLira=Xultophy

Figure 2 Mean HbA1c (%) by treatment week in patients with type 2 diabetes mellitus inadequately controlled on sulfonylurea alone or in combination with metformin

The rate per patient year of exposure (percentage of patients) of severe hypoglycaemia was 0.02 (2 patients out of 288) for Xultophy and 0.00 (0 patients out of 146) for placebo.

Table 3 Results at 26-weeks – Add on to oral glucose-lowering medicinal products Add on to sulfonylurea ± Add on to metformin ± pioglitazone metformin Xultophy Insulin degludec Liraglutide Xultophy Placebo N 833 413 414 289 146

HbA1c (%) Baseline→End of trial 8.3→6.4 8.3→6.9 8.3→7.0 7.9→6.4 7.9→7.4 Mean change -1.91 -1.44 -1.28 -1.45 -0.46 Estimated difference -0.47AB[-0.58; -0.36] -0.64AB[-0.75; -0.53] -1.02AB[-1.18; -0.87] Patients (%) achieving

HbA1c <7% All patients 80.6 65.1 60.4 79.2 28.8 Estimated odds ratio 2.38B [1.78; 3.18] 3.26B [2.45; 4.33] 11.95B [7.22; 19.77]

12 Patients (%) achieving

HbA1c ≤6.5% All patients 69.7 47.5 41.1 64.0 12.3 Estimated odds ratio 2.82B [2.17; 3.67] 3.98B [3.05; 5.18] 16.36B [9.05; 29.56] Rate of confirmed hypoglycaemia* per patient year of exposure (percentage of patients) 1.80 (31.9%) 2.57 (38.6%) 0.22 (6.8%) 3.52 (41.7%) 1.35 (17.1%) Estimated ratio 0.68AC [0.53; 0.87] 7.61B [5.17; 11.21] 3.74B [2.28; 6.13] Body Weight (kg) Baseline→End of trial 87.2→86.7 87.4→89.0 87.4→84.4 87.2→87.7 89.3→88.3 Mean change -0.5 1.6 -3.0 0.5 -1.0 Estimated difference -2.22AB [-2.64; -1.80] 2.44B [2.02; 2.86] 1.48B [0.90; 2.06] FPG (mmol/L) Baseline→End of trial 9.2→5.6 9.4→5.8 9.0→7.3 9.1→6.5 9.1→8.8 Mean change -3.62 -3.61 -1.75 -2.60 -0.31 Estimated difference -0.17 [-0.41; 0.07] -1.76B [-2.0; -1.53] -2.30B [-2.72; -1.89] Dose End of trial Insulin degludec (units) 38 53 - 28 - Liraglutide (mg) 1.4 - 1.8 1.0 - Estimated difference, -14.90AB [-17.14; - insulin degludec dose -12.66] Baseline, End of trial and change values are observed Last observation carried forward. The 95% confidence interval is stated in ‘[]’ *Confirmed hypoglycaemia defined as severe hypoglycaemia (episode requiring assistance of another person) and/or minor hypoglycaemia (plasma glucose <3.1 mmol/L irrespective of symptoms) A Endpoints with confirmed superiority of Xultophy vs comparator B p<0.0001 C p<0.05

In an open label trial comparing the efficacy and safety of Xultophy and insulin glargine 100 units/mL, both as add-on to SGLT2i ± OAD, Xultophy was superior to insulin glargine in reducing mean HbA1c after 26 weeks by 1.9% (from 8.2% to 6.3%) versus 1.7% (from 8.4% to 6.7%) with an estimated treatment difference of -0.36% [-0.50; -0.21]. Compared to baseline, Xultophy resulted in an unchanged mean body weight compared to a mean weight increase of 2.0 kg for patients treated with insulin glargine (estimated treatment difference -1.92 kg [95% CI: -2.64; -1.19]). The percentage of patients experiencing severe or blood-glucose confirmed symptomatic hypoglycaemia was 12.9% in the Xultophy group and 19.5% in the insulin glargine group (estimated treatment ratio 0.42 [95% CI: 0.23; 0.75]). The mean daily insulin dose at end of trial was 36 units for patients treated with Xultophy and 54 units for patients treated with insulin glargine.

Transfer from GLP-1 receptor agonist therapy Transfer from GLP-1 receptor agonist to Xultophy compared to unchanged GLP-1 receptor agonist therapy (dosed according to label) were studied in a 26-weeks randomised, open-label trial in patients with type 2 diabetes mellitus inadequately controlled on a GLP-1 receptor agonist and metformin alone (74.2%) or in combination with pioglitazone (2.5%), sulfonylurea (21.2%) or both (2.1%). The key results of the trial are listed in Figure 3 and Table 4.

IDegLira Unchanged GLP-1 RA

HbA1c (%)

Time since Randomisation (Week) IDegLira=Xultophy, GLP-1 RA=GLP-1 receptor agonist

Figure 3 Mean HbA1c (%) by treatment week in patients with type 2 diabetes mellitus

13 inadequately controlled on GLP-1 receptor agonists

The rate per patient year of exposure (percentage of patients) of severe hypoglycaemia was 0.01 (1 patient out of 291) for Xultophy and 0.00 (0 patients out of 199) for GLP-1 receptor agonists.

Table 4 Results at 26-weeks – Transfer from GLP-1 receptor agonists Transfer from GLP-1 receptor agonist Xultophy GLP-1 receptor agonist N 292 146 HbA1c (%) Baseline→End of trial 7.8→6.4 7.7→7.4 Mean change -1.3 -0.3 Estimated difference -0.94AB[-1.11; -0.78] Patients (%) achieving HbA1c <7% All patients 75.3 35.6 Estimated odds ratio 6.84B [4.28; 10.94]

Patients (%) achieving HbA1c ≤6.5% All patients 63.0 22.6 Estimated odds ratio 7.53B [4.58; 12.38] Rate of confirmed hypoglycaemia* per patient year of exposure (percentage of patients) 2.82 (32.0%) 0.12 (2.8%) Estimated ratio 25.36B [10.63; 60.51] Body Weight (kg) Baseline→End of trial 95.6→97.5 95.5→94.7 Mean change 2.0 -0.8 Estimated difference 2.89B [2.17; 3.62] FPG (mmol/L) Baseline→End of trial 9.0→6.0 9.4→8.8 Mean change -2.98 -0.60 Estimated difference -2.64B [-3.03; -2.25]

Dose End of trial 43 GLP-1 receptor agonist dose was to Insulin degludec (units) 1.6 be continued unchanged from Liraglutide (mg) baseline Estimated difference, insulin degludec dose

Baseline, End of trial and change values are observed Last observation carried forward. The 95% confidence interval is stated in ‘[]’ *Confirmed hypoglycaemia defined as severe hypoglycaemia (episode requiring assistance of another person) and/or minor hypoglycaemia (plasma glucose <3.1 mmol/L irrespective of symptoms) A Endpoints with confirmed superiority of Xultophy vs comparator B p<0.001

Transfer from basal insulin therapies Transfer of patients from insulin glargine (100 units/mL) to Xultophy or intensification of insulin glargine in patients inadequately controlled on insulin glargine (20-50 units) and metformin were studied in a 26 week trial. The maximum allowed dose in the trial was 50 dose steps for Xultophy whereas there was no maximum dose for insulin glargine. 54.3% of patients treated with Xultophy reached the HbA1c target of <7% without confirmed hypoglycaemic episodes compared to 29.4% of patients treated with insulin glargine (odds ratio 3.24, p<0.001).

The key results of the trial are listed in Figure 4 and Table 5.

IDegLira

IGlar HbA1c (%)

Time since randomisation (week)

IDegLira=Xultophy, IGlar=insulin glargine

Figure 4 Mean HbA1c (%) by treatment week in patients with type 2 diabetes mellitus inadequately controlled on insulin glargine

14 The rate per patient year of exposure (percentage of patients) of severe hypoglycaemia was 0.00 (0 patients out of 278) for Xultophy and 0.01 (1 patient out of 279) for insulin glargine. The rate of nocturnal hypoglycaemic events was significantly lower with Xultophy compared to insulin glargine (estimated treatment ratio 0.17, p<0.001).

In a second trial, the transfer from basal insulin to Xultophy or insulin degludec was investigated in a 26-week randomised, double-blind trial in patients inadequately controlled on basal insulin (20-40 units) and metformin alone or in combination with sulfonylurea/glinides. Basal insulin and sulfonylurea/glinides were discontinued at randomisation. The maximum allowed dose was 50 dose steps for Xultophy and 50 units for insulin degludec. 48.7% of patients treated with Xultophy reached the HbA1c target of <7% without confirmed hypoglycaemic episodes. This was a significantly higher proportion than observed with insulin degludec (15.6%, odds ratio 5.57, p<0.0001). The key results of the trial are listed in Figure 5 and Table 5.

IDegLira IDeg

HbA1c (%)

Time since Randomisation (Week) IDegLira=Xultophy, IDeg=insulin degludec

Figure 5 Mean HbA1c (%) by treatment week in patients with type 2 diabetes mellitus inadequately controlled on basal insulin

The rate per patient year of exposure (percentage of patients) of severe hypoglycaemia was 0.01 (1 patient out of 199) for Xultophy and 0.00 (0 patients out of 199) for insulin degludec. The rate of nocturnal hypoglycaemic events was similar with Xultophy and insulin degludec treatment.

Table 5 Results at 26-weeks – Transfer from basal insulin Transfer from insulin glargine (100 Transfer from basal insulin (NPH, insulin

units/mL) detemir, insulin glargine) Xultophy Insulin glargine, no Xultophy Insulin degludec, maximum

limitation to dose 50 units allowed N 278 279 199 199

HbA1c (%) Baseline→End of trial 8.4→6.6 8.2→7.1 8.7→6.9 8.8→8.0 Mean change -1.81 -1.13 -1.90 -0.89 Estimated difference -0.59AB[-0.74; -0.45] -1.05AB[-1.25; -0.84] Patients (%) achieving

HbA1c <7% All patients 71.6 47.0 60.3 23.1 Estimated odds ratio 3.45B [2.36; 5.05] 5.44B [3.42; 8.66] Patients (%) achieving

HbA1c ≤6.5% All patients 55.4 30.8 45.2 13.1 Estimated odds ratio 3.29B [2.27; 4.75] 5.66B [3.37; 9.51] Rate of confirmed hypoglycaemia* per patient year of exposure (percentage of patients) 2.23 (28.4%) 5.05 (49.1%) 1.53 (24.1%) 2.63 (24.6%) Estimated ratio 0.43AB [0.30; 0.61] 0.66 [0.39; 1.13] Body Weight (kg) Baseline→End of trial 88.3→86.9 87.3→89.1 95.4→92.7 93.5→93.5 Mean change -1.4 1.8 -2.7 0.0 Estimated difference

15 -3.20AB [-3.77; -2.64] -2.51B [-3.21; -1.82] FPG (mmol/L) Baseline→End of trial 8.9→6.1 8.9→6.1 9.7→6.2 9.6→7.0 Mean change -2.83 -2.77 -3.46 -2.58 Estimated difference -0.01 [-0.35; 0.33] -0.73C [-1.19; -0.27] Dose End of trial Insulin (units) 41 66D 45 45 Liraglutide (mg) 1.5 - 1.7 - Estimated difference, -25.47B [-28.90; -22.05] -0.02 [-1.88; 1.84] basal insulin dose Baseline, End of trial and change values are observed Last observation carried forward. The 95% confidence interval is stated in ‘[]’ *Confirmed hypoglycaemia defined as severe hypoglycaemia (episode requiring assistance of another person) and/or minor hypoglycaemia (plasma glucose <3.1 mmol/L irrespective of symptoms) A Endpoints with confirmed superiority of Xultophy vs comparator B p<0.0001 C p<0.05 D The average pre-trial dose of insulin glargine was 32 units

Treatment with Xultophy compared to a basal-bolus insulin regimen consisting of basal insulin (insulin glargine 100 units/mL) in combination with bolus insulin (insulin aspart) studied in a 26-week trial in patients with type 2 diabetes mellitus inadequately controlled on insulin glargine and metformin demonstrated a similar reduction of HbA1c in the two groups (mean value from 8.2% to 6.7% in both groups). In both groups 66%–67% achieved HbA1c < 7%. Compared to baseline, there was a mean reduction in body weight of 0.9 kg for Xultophy and a mean increase of 2.6 kg for patients treated with a basal-bolus regimen and the estimated treatment difference was -3.57 kg [95% CI: - 4.19; -2.95]. The percentage of patients experiencing severe or blood-glucose confirmed symptomatic hypoglycaemia was 19.8% in the Xultophy group and 52.6% in the basal-bolus insulin group, and the estimated rate ratio was 0.11 [95% CI: 0.08-0.17]. The total daily insulin dose at end of trial was 40 units for patients treated with Xultophy and 84 units (52 units of basal insulin and 32 units of bolus insulin) for patients treated with a basal-bolus insulin regimen.

• Cardiovascular Safety

No cardiovascular outcomes trials have been performed with Xultophy.

Liraglutide (Victoza) The Liraglutide Effect and Action in Diabetes Evaluation of Cardiovascular Outcome Results (LEADER) trial, was a multicentre, placebo-controlled, double-blind clinical trial. 9,340 patients were randomly allocated to either liraglutide (4,668) or placebo (4,672), both in addition to standards of care for HbA1c and cardiovascular (CV) risk factors. Primary outcome or vital status at end of trial was available for 99.7% and 99.6% of participants randomised to liraglutide and placebo, respectively. The duration of observation was minimum 3.5 years and up to a maximum of 5 years. The study population included patients ≥65 years (n=4,329) and ≥75 years (n=836) and patients with mild (n=3,907), moderate (n=1,934) or severe (n=224) renal impairment. The mean age was 64 years and the mean BMI was 32.5 kg/m². The mean duration of diabetes was 12.8 years.

The primary endpoint was the time from randomisation to first occurrence of any major adverse cardiovascular events (MACE): CV death, non-fatal myocardial infarction or non-fatal stroke. Liraglutide was superior in preventing MACE vs placebo (Figure 6).

16 Hazard Ratio Liraglutide N Placebo N (95% CI) (%) (%) 4668 4672 FAS (100) (100) 0.87 608 694 Primary endpoint – MACE (0.78-0.97) (13.0) (14.9)

Components of MACE: 0.78 219 278 Cardiovascular death (0.66-0.93) (4.7) (6.0) 0.89 159 177 Non-fatal stroke (0.72-1.11) (3.4) (3.8) 0.88 281 317 Non-fatal myocardial infarction (0.75-1.03) (6.0) (6.8)

0.88 948 1062 Expanded MACE (0.81-0.96) (20.3) (22.7)

Additional components in expanded MACE: 0.98 122 124 Unstable angina pectoris (hospitalisation) (0.76-1.26) (2.6) (2.7) 0.91 405 441 Coronary revascularisation (0.80-1.04) (8.7) (9.4) 0.87 218 248 Heart failure (hospitalisation) (0.73-1.05) (4.7) (5.3)

Other secondary endpoints: 0.85 381 447 All cause death (0.74-0.97) (8.2) (9.6) 0.95 162 169 Non-cardiovascular death (0.77-1.18) (3.5) (3.6)

FAS: full analysis set CI: confidence interval 0.7 0.8 0.9 1 1.1 1.2 MACE: major adverse cardiovascular event Favours Liraglutide Favours Placebo %: proportion in percent of subjects with an event N: number of subjects

Figure 6 Forest plot of analyses of individual cardiovascular event types – FAS population

A reduction in HbA1c from baseline to month 36 was observed with liraglutide vs placebo, in addition to standard of care (-1.16% vs -0.77%; estimated treatment difference [ETD] -0.40% [-0.45; -0.34]).

Insulin degludec (Tresiba) DEVOTE was a randomised, double-blind, and event-driven clinical trial with a median duration of 2 years comparing the cardiovascular safety of insulin degludec versus insulin glargine (100 units/mL) in 7,637 patients with type 2 diabetes mellitus at high risk of cardiovascular events. The primary analysis was time from randomisation to first occurrence of a 3-component major adverse cardiovascular event (MACE) defined as cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke. The trial was designed as a non-inferiority trial to exclude a pre-specified risk margin of 1.3 for the hazard ratio (HR) of MACE comparing insulin degludec to insulin glargine. The cardiovascular safety of insulin degludec as compared to insulin glargine was confirmed (HR 0.91 [0.78; 1.06]) (Figure 7).

At baseline, HbA1c was 8.4% in both treatment groups and after 2 years HbA1c was 7.5% both with insulin degludec and insulin glargine.

Hazard Ratio Insulin degludec Insulin glargine (95% CI) N (%) N (%)

Primary analysis (3-point MACE) 0.91 (0.78-1.06) 325 (8.51) 356 (9.32)

CV Death 0.96 (0.76-1.21) 136 (3.56) 142 (3.72)

Non-fatal Stroke 0.90 (0.65-1.23) 71 (1.86) 79 (2.07)

Non-fatal MI 0.85 (0.68-1.06) 144 (3.77) 169 (4.43)

All cause death 0.91 (0.75-1.11) 202 (5.29) 221 (5.79)

0.7 0.9 1 1.1 1.3 Favours Favours insulin degludec insulin glargine

N: Number of subjects with a first EAC confirmed event during trial. %: Percentage of subjects with a first EAC confirmed event relative to the number of randomised subjects. EAC: Event adjudication committee. CV: Cardiovascular. MI: Myocardial infarction. CI: 95% confidence interval.

17 Figure 7 Forest plot of analysis of the composite 3-point MACE and individual cardiovascular endpoints in DEVOTE

• Insulin secretion/beta-cell function Xultophy improves beta-cell function compared to insulin degludec as measured by the homeostasis model assessment for beta-cell function (HOMA-β). Improved insulin secretion compared to insulin degludec in response to a standardised meal test was demonstrated in 260 patients with type 2 diabetes after 52 weeks of treatment. No data is available beyond 52 weeks of treatment.

• Blood pressure In patients inadequately controlled on metformin alone or in combination with pioglitazone, Xultophy reduced mean systolic blood pressure by 1.8 mmHg compared to a reduction of 0.7 mmHg with insulin degludec and 2.7 mmHg with liraglutide. In patients inadequately controlled on sulfonylurea alone or in combination with metformin, the reduction was 3.5 mmHg with Xultophy and 3.2 mmHg with placebo. The differences were not statistically significant. In three trials with patients inadequately controlled on basal insulin, systolic blood pressure was reduced by 5.4 mmHg with Xultophy and 1.7 mmHg with insulin degludec, with a statistically significant estimated treatment difference of -3.71 mmHg (p=0.0028), reduced by 3.7 mmHg with Xultophy vs 0.2 mmHg with insulin glargine, with a statistically significant estimated treatment difference of -3.57 mmHg (p<0.001) and reduced by 4.5 mmHg with Xultophy vs 1.16 mmHg with insulin glargine U100 plus insulin aspart, with a statistically significant estimated treatment difference of -3.70 mmHg (p=0.0003).

Paediatric population The European Medicines Agency has waived the obligation to submit the results of studies with Xultophy in all subsets of the paediatric population for treatment of type 2 diabetes mellitus (see section 4.2 for information on paediatric use).

5.2 Pharmacokinetic properties

Overall, the pharmacokinetics of insulin degludec and liraglutide were not affected in a clinically relevant manner when administered as Xultophy compared with independent injections of insulin degludec and liraglutide.

The following reflects the pharmacokinetic properties of Xultophy unless stated that the presented data is from administration of insulin degludec or liraglutide alone.

Absorption

The overall exposure of insulin degludec was equivalent following administration of Xultophy versus insulin degludec alone while the Cmax was higher by 12%. The overall exposure of liraglutide was equivalent following administration of Xultophy versus liraglutide alone while Cmax was lower by 23%. The differences are considered of no clinical relevance since Xultophy is initiated and titrated according to the individual patient’s blood glucose targets.

Insulin degludec and liraglutide exposure increased proportionally with the Xultophy dose within the full dose range based on a population pharmacokinetic analysis.

The pharmacokinetic profile of Xultophy is consistent with once-daily dosing and steady-state concentration of insulin degludec and liraglutide is reached after 2–3 days of daily administration.

Distribution

Insulin degludec and liraglutide are extensively bound to plasma proteins (>99% and >98%, respectively).

Biotransformation

18

Insulin degludec Degradation of insulin degludec is similar to that of human insulin; all metabolites formed are inactive.

Liraglutide During 24 hours following administration of a single radiolabelled [3H]-liraglutide dose to healthy subjects, the major component in plasma was intact liraglutide. Two minor plasma metabolites were detected (≤9% and ≤5% of total plasma radioactivity exposure). Liraglutide is metabolised in a similar manner to large proteins without a specific organ having been identified as major route of elimination.

Elimination

The half-life of insulin degludec is approximately 25 hours and the half-life of liraglutide is approximately 13 hours.

Special populations

Elderly patients Age had no clinically relevant effect on the pharmacokinetics of Xultophy based on results from a population pharmacokinetic analysis including adult patients up to 83 years treated with Xultophy.

Gender Gender had no clinically relevant effect on the pharmacokinetics of Xultophy based on results from a population pharmacokinetic analysis.

Ethnic origin Ethnic origin had no clinically relevant effect on the pharmacokinetics of Xultophy based on results from a population pharmacokinetic analysis including White, Black, Indian, Asian and Hispanic groups.

Renal impairment Insulin degludec There is no difference in the pharmacokinetics of insulin degludec between healthy subjects and patients with renal impairment.

Liraglutide Liraglutide exposure was reduced in patients with renal impairment compared to individuals with normal renal function. Liraglutide exposure was lowered by 33%, 14%, 27% and 26%, in patients with mild (creatinine clearance, CrCl 50–80 mL/min), moderate (CrCl 30–50 mL/min), and severe (CrCl <30 mL/min) renal impairment and in end-stage renal disease requiring dialysis, respectively. Similarly, in a 26-week clinical trial, patients with type 2 diabetes and moderate renal impairment (CrCl 30–59 mL/min) had 26% lower liraglutide exposure when compared with a separate trial including patients with type 2 diabetes with normal renal function or mild renal impairment.

Hepatic impairment Insulin degludec There is no difference in the pharmacokinetics of insulin degludec between healthy subjects and patients with hepatic impairment.

Liraglutide The pharmacokinetics of liraglutide was evaluated in patients with varying degrees of hepatic impairment in a single-dose trial. Liraglutide exposure was decreased by 13–23% in patients with mild to moderate hepatic impairment compared to healthy subjects. Exposure was significantly lower (44%) in patients with severe hepatic impairment (Child Pugh score >9).

Paediatric population

19 No studies have been performed with Xultophy in children and adolescents below 18 years of age.

5.3 Preclinical safety data

The non-clinical development programme for insulin degludec/liraglutide included pivotal combination toxicity studies of up to 90 days duration in a single relevant species (Wistar rats) to support the clinical development programme. Local tolerance was assessed in rabbits and pigs.

Non-clinical safety data revealed no safety concern for humans based on repeated dose toxicity studies.

The local tissue reactions in the two studies in rabbits and pigs, respectively, were limited to mild inflammatory reactions.

No studies have been conducted with the insulin degludec/liraglutide combination to evaluate carcinogenesis, mutagenesis or impairment of fertility. The following data are based upon studies with insulin degludec and liraglutide individually.

Insulin degludec Non-clinical data reveal no safety concern for humans based on studies of safety pharmacology, repeated dose toxicity, carcinogenic potential, and toxicity to reproduction. The ratio of mitogenic relative to metabolic potency for insulin degludec is unchanged compared to human insulin.

Liraglutide Non-clinical data reveal no special hazards for human based on conventional studies of safety pharmacology, repeat-dose toxicity, or genotoxicity. Non-lethal thyroid C-cell tumours were seen in 2-year carcinogenicity studies in rats and mice. In rats, a no observed adverse effect level (NOAEL) was not observed. These tumours were not seen in monkeys treated for 20 months. These findings in rodents are caused by a non-genotoxic, specific GLP-1 receptor-mediated mechanism to which rodents are particularly sensitive. The relevance for humans is likely to be low but cannot be completely excluded. No other treatment-related tumours have been found.

Animal studies did not indicate direct harmful effects with respect to fertility but slightly increased early embryonic deaths at the highest dose. Dosing with liraglutide during mid-gestation caused a reduction in maternal weight and foetal growth with equivocal effects on ribs in rats and skeletal variation in the rabbit. Neonatal growth was reduced in rats while exposed to liraglutide, and persisted in the post-weaning period in the high dose group. It is unknown whether the reduced pup growth is caused by reduced pup milk intake due to a direct GLP-1 effect or reduced maternal milk production due to decreased caloric intake.

6. PHARMACEUTICAL PARTICULARS

6.1 List of excipients

Glycerol Phenol Zinc acetate Hydrochloric acid (for pH adjustment) Sodium hydroxide (for pH adjustment) Water for injections

6.2 Incompatibilities

Substances added to Xultophy may cause degradation of the active substances.

20 Xultophy must not be added to infusion fluids.

This medicinal product must not be mixed with other medicinal products.

6.3 Shelf life

2 years.

After first opening, the medicinal product can be stored for 21 days at a maximum temperature of 30°C. The medicinal product should be discarded 21 days after first opening.

6.4 Special precautions for storage

Before first opening: Store in a refrigerator (2°C – 8°C). Keep away from the freezing element. Do not freeze. Keep the cap on the pre-filled pen in order to protect from light.

After first opening: Store at a maximum of 30°C or store in a refrigerator (2°C – 8°C). Do not freeze. Keep the cap on the pre-filled pen in order to protect from light.

For storage conditions after first opening of the medicinal product, see section 6.3.

6.5 Nature and contents of container

3 mL solution in a cartridge (type 1 glass) with a plunger (halobutyl) and a stopper (halobutyl/polyisoprene) contained in a pre-filled multidose disposable pen made of polypropylene, polycarbonate and acrylonitrile butadiene styrene.

Pack sizes of 1, 3, 5 and multipack containing 10 (2 packs of 5) pre-filled pens.

Not all pack sizes may be marketed.

6.6 Special precautions for disposal and other handling

The pre-filled pen is designed to be used with NovoTwist or NovoFine injection needles up to a length of 8 mm and as thin as 32G.

The pre-filled pen is for use by one person only.

Xultophy must not be used if the solution does not appear clear and colourless.

Xultophy which has been frozen must not be used.

A new needle must always be attached before each use. Needles must not be re-used. The patient should discard the needle after each injection.

In the event of blocked needles, patients must follow the instructions described in the instructions for use accompanying the package leaflet.

Any unused medicinal product or waste material should be disposed of in accordance with local requirements.

For detailed instructions for use, see the package leaflet.

7. MARKETING AUTHORISATION HOLDER

Novo Nordisk A/S

21 Novo Allé DK-2880 Bagsværd Denmark

8. MARKETING AUTHORISATION NUMBERS

EU/1/14/947/001 EU/1/14/947/002 EU/1/14/947/003 EU/1/14/947/004

9. DATE OF FIRST AUTHORISATION/RENEWAL OF THE AUTHORISATION

Date of first authorisation: 18 September 2014 Date of latest renewal: 08 July 2019

10. DATE OF REVISION OF THE TEXT

Detailed information on this medicinal product is available on the website of the European Medicines Agency http://www.ema.europa.eu.

22

ANNEX II

A. MANUFACTURERS OF THE BIOLOGICAL ACTIVE SUBSTANCES AND MANUFACTURERS RESPONSIBLE FOR BATCH RELEASE

B. CONDITIONS OR RESTRICTIONS REGARDING SUPPLY AND USE

C. OTHER CONDITIONS AND REQUIREMENTS OF THE MARKETING AUTHORISATION

D. CONDITIONS OR RESTRICTIONS WITH REGARD TO THE SAFE AND EFFECTIVE USE OF THE MEDICINAL PRODUCT

23 A. MANUFACTURER OF THE BIOLOGICAL ACTIVE SUBSTANCES AND MANUFACTURER RESPONSIBLE FOR BATCH RELEASE

Name and address of the manufacturer of the biological active substances

Novo Nordisk A/S Hallas Alle, Kalundborg, 4400, Denmark

Novo Nordisk A/S Novo Allé, Bagsværd, 2880, Denmark

Name and address of the manufacturer responsible for batch release

Novo Nordisk A/S Novo Allé, Bagsværd, 2880, Denmark

B. CONDITIONS OR RESTRICTIONS REGARDING SUPPLY AND USE

Medicinal product subject to medical prescription.

C. OTHER CONDITIONS AND REQUIREMENTS OF THE MARKETING AUTHORISATION

• Periodic safety update reports (PSURs)

The requirements for submission of PSURs for this medicinal product are set out in the list of Union reference dates (EURD list) provided for under Article 107c(7) of Directive 2001/83/EC and any subsequent updates published on the European medicines web-portal.

D. CONDITIONS OR RESTRICTIONS WITH REGARD TO THE SAFE AND EFFECTIVE USE OF THE MEDICINAL PRODUCT

• Risk management plan (RMP)

The marketing authorisation holder (MAH) shall perform the required pharmacovigilance activities and interventions detailed in the agreed RMP presented in Module 1.8.2 of the marketing authorisation and any agreed subsequent updates of the RMP.

An updated RMP should be submitted: • At the request of the European Medicines Agency; • Whenever the risk management system is modified, especially as the result of new information being received that may lead to a significant change to the benefit/risk profile or as the result of an important (pharmacovigilance or risk minimisation) milestone being reached.

• Additional risk minimisation measures

The MAH shall provide educational materials prior to launch targeting all physicians and nurses who are expected to be involved in the treatment and management of diabetic patients and all pharmacists who are expected to dispense Xultophy.

The MAH shall agree the final content and modality of distribution for the educational materials together with a communication plan, with the National Competent Authority in each Member State prior to distribution of the educational materials in the Member State.

24 The educational materials are aimed at increasing awareness about the fact Xultophy contains a fixed combination of insulin degludec and liraglutide (a GLP1-based product) and at minimising the risk of medication errors with Xultophy.

The MAH shall ensure that healthcare professionals are informed that all patients who have been prescribed Xultophy should be trained on the correct use of the prefilled pen before prescribing or dispensing Xultophy.

The educational materials should contain: - Summary of product characteristics and package leaflet; - Healthcare professional brochure that should contain the following key elements: • this product contains a fixed combination of insulin degludec plus liraglutide (a GLP1-based product) which constitutes a new treatment paradigm in the treatment of patients with type 2 diabetes. In this context, relevant precautions as reflected in the SmPC should be emphasised. • a clear explanation of the posology of the product and the meaning of ‘dose steps’ - with reference to dose of each component for each dose step • a reminder of the need to report all medication errors irrespective of whether or not they resulted in an adverse event.

25

ANNEX III

LABELLING AND PACKAGE LEAFLET

26

A. LABELLING

27 PARTICULARS TO APPEAR ON THE OUTER PACKAGING

OUTER CARTON

1. NAME OF THE MEDICINAL PRODUCT

Xultophy 100 units/mL + 3.6 mg/mL solution for injection insulin degludec + liraglutide

2. STATEMENT OF ACTIVE SUBSTANCES

One pre-filled pen contains 300 units insulin degludec and 10.8 mg liraglutide in 3 mL solution 1 mL solution contains 100 units of insulin degludec and 3.6 mg liraglutide One dose step contains 1 unit of insulin degludec and 0.036 mg of liraglutide

3. LIST OF EXCIPIENTS

Glycerol, phenol, zinc acetate, hydrochloric acid and sodium hydroxide (for pH adjustment), and water for injections

4. PHARMACEUTICAL FORM AND CONTENTS

Solution for injection

1x3 mL 3x3 mL 5x3 mL

5. METHOD AND ROUTE OF ADMINISTRATION

Recommended for use with NovoTwist or NovoFine disposable needles Needles are not included Read the package leaflet before use Subcutaneous use

6. SPECIAL WARNING THAT THE MEDICINAL PRODUCT MUST BE STORED OUT OF THE SIGHT AND REACH OF CHILDREN

Keep out of the sight and reach of children

7. OTHER SPECIAL WARNINGS, IF NECESSARY

Use only clear, colourless solution For use by one person only Do not withdraw solution from the pen

8. EXPIRY DATE

28

EXP After first opening: Use within 21 days

9. SPECIAL STORAGE CONDITIONS

Store in a refrigerator Do not freeze After first opening: Store at a maximum of 30°C or store in a refrigerator Keep the cap on the pen to protect from light

10. SPECIAL PRECAUTIONS FOR DISPOSAL OF UNUSED MEDICINAL PRODUCTS OR WASTE MATERIALS DERIVED FROM SUCH MEDICINAL PRODUCTS, IF APPROPRIATE

Discard the needle after each injection

11. NAME AND ADDRESS OF THE MARKETING AUTHORISATION HOLDER

Novo Nordisk A/S Novo Allé DK-2880 Bagsværd Denmark

12. MARKETING AUTHORISATION NUMBERS

EU/1/14/947/001 1 pre-filled pen EU/1/14/947/002 3 pre-filled pens EU/1/14/947/003 5 pre-filled pens

13. BATCH NUMBER

Batch

14. GENERAL CLASSIFICATION FOR SUPPLY

15. INSTRUCTIONS ON USE

16. INFORMATION IN BRAILLE

Xultophy

17. UNIQUE IDENTIFIER – 2D BARCODE

2D barcode carrying the unique identifier included.

29

18. UNIQUE IDENTIFIER – HUMAN READABLE DATA

PC: SN: NN:

30 MINIMUM PARTICULARS TO APPEAR ON SMALL IMMEDIATE PACKAGING UNITS

PEN LABEL

1. NAME OF THE MEDICINAL PRODUCT AND ROUTE OF ADMINISTRATION

Xultophy 100 units/mL + 3.6 mg/mL solution for injection insulin degludec + liraglutide SC use

2. METHOD OF ADMINISTRATION

3. EXPIRY DATE

EXP

4. BATCH NUMBER

Batch

5. CONTENTS BY WEIGHT, BY VOLUME OR BY UNIT

3 mL

6. OTHER

Novo Nordisk A/S

31 PARTICULARS TO APPEAR ON THE OUTER PACKAGING

MULTIPACK LABEL (with blue box)

1. NAME OF THE MEDICINAL PRODUCT

Xultophy 100 units/mL + 3.6 mg/mL solution for injection insulin degludec + liraglutide

2. STATEMENT OF ACTIVE SUBSTANCES

One pre-filled pen contains 300 units insulin degludec and 10.8 mg liraglutide in 3 mL solution 1 mL solution contains 100 units of insulin degludec and 3.6 mg liraglutide One dose step contains 1 unit of insulin degludec and 0.036 mg of liraglutide

3. LIST OF EXCIPIENTS

Glycerol, phenol, zinc acetate, hydrochloric acid and sodium hydroxide (for pH adjustment), and water for injections

4. PHARMACEUTICAL FORM AND CONTENTS

Solution for injection

Multipack: 10 (2 packs of 5) 3 mL pre-filled pens

5. METHOD AND ROUTE OF ADMINISTRATION

Recommended for use with NovoTwist or NovoFine disposable needles Needles are not included Read the package leaflet before use Subcutaneous use

6. SPECIAL WARNING THAT THE MEDICINAL PRODUCT MUST BE STORED OUT OF THE SIGHT AND REACH OF CHILDREN

Keep out of the sight and reach of children

7. OTHER SPECIAL WARNINGS, IF NECESSARY

Use only clear, colourless solution For use by one person only Do not withdraw solution from the pen

8. EXPIRY DATE

EXP

32 After first opening: Use within 21 days

9. SPECIAL STORAGE CONDITIONS

Store in a refrigerator Do not freeze After first opening: Store at a maximum of 30°C or store in a refrigerator Keep the cap on the pen to protect from light

10. SPECIAL PRECAUTIONS FOR DISPOSAL OF UNUSED MEDICINAL PRODUCTS OR WASTE MATERIALS DERIVED FROM SUCH MEDICINAL PRODUCTS, IF APPROPRIATE

Discard the needle after each injection

11. NAME AND ADDRESS OF THE MARKETING AUTHORISATION HOLDER

Novo Nordisk A/S Novo Allé DK-2880 Bagsværd Denmark

12. MARKETING AUTHORISATION NUMBERS

EU/1/14/947/004 10 (2 x 5) pre-filled pens

13. BATCH NUMBER

Batch

14. GENERAL CLASSIFICATION FOR SUPPLY

15. INSTRUCTIONS ON USE

16. INFORMATION IN BRAILLE

Xultophy

17. UNIQUE IDENTIFIER – 2D BARCODE

2D barcode carrying the unique identifier included.

18. UNIQUE IDENTIFIER - HUMAN READABLE DATA

PC:

33 SN: NN:

34

PARTICULARS TO APPEAR ON THE INNER PACKAGING

CARTON FOR MULTIPACK (without blue box)

1. NAME OF THE MEDICINAL PRODUCT

Xultophy 100 units/mL + 3.6 mg/mL solution for injection insulin degludec + liraglutide

2. STATEMENT OF ACTIVE SUBSTANCES

One pre-filled pen contains 300 units insulin degludec and 10.8 mg liraglutide in 3 mL solution 1 mL solution contains 100 units of insulin degludec and 3.6 mg liraglutide One dose step contains 1 unit of insulin degludec and 0.036 mg of liraglutide

3. LIST OF EXCIPIENTS

Glycerol, phenol, zinc acetate, hydrochloric acid and sodium hydroxide (for pH adjustment), and water for injections

4. PHARMACEUTICAL FORM AND CONTENTS

Solution for injection

5 pre-filled pens of 3 mL. Component of a multipack, can’t be sold separately

5. METHOD AND ROUTE OF ADMINISTRATION

Recommended for use with NovoTwist or NovoFine disposable needles Needles are not included Read the package leaflet before use Subcutaneous use

6. SPECIAL WARNING THAT THE MEDICINAL PRODUCT MUST BE STORED OUT OF THE SIGHT AND REACH OF CHILDREN

Keep out of the sight and reach of children

7. OTHER SPECIAL WARNINGS, IF NECESSARY

Use only clear, colourless solution For use by one person only Do not withdraw solution from the pen

8. EXPIRY DATE

35 EXP After first opening: Use within 21 days

9. SPECIAL STORAGE CONDITIONS

Store in a refrigerator Do not freeze After first opening: Store at a maximum of 30°C or store in a refrigerator Keep the cap on the pen to protect from light

10. SPECIAL PRECAUTIONS FOR DISPOSAL OF UNUSED MEDICINAL PRODUCTS OR WASTE MATERIALS DERIVED FROM SUCH MEDICINAL PRODUCTS, IF APPROPRIATE

Discard the needle after each injection

11. NAME AND ADDRESS OF THE MARKETING AUTHORISATION HOLDER

Novo Nordisk A/S Novo Allé DK-2880 Bagsværd Denmark

12. MARKETING AUTHORISATION NUMBERS

EU/1/14/947/004 10 (2 x 5) pre-filled pens

13. BATCH NUMBER

Batch

14. GENERAL CLASSIFICATION FOR SUPPLY

15. INSTRUCTIONS ON USE

16. INFORMATION IN BRAILLE

Xultophy

17. UNIQUE IDENTIFIER – 2D BARCODE

18. UNIQUE IDENTIFIER – HUMAN READABLE DATA

36

B. PACKAGE LEAFLET

37 Package leaflet: Information for the patient

Xultophy 100 units/mL + 3.6 mg/mL solution for injection insulin degludec + liraglutide

Read all of this leaflet carefully before you start using this medicine because it contains important information for you. • Keep this leaflet. You may need to read it again. • If you have any further questions, ask your doctor, pharmacist or nurse. • This medicine has been prescribed for you only. Do not pass it on to others. It may harm them, even if their signs of illness are the same as yours. • If you get any side effects, talk to your doctor, pharmacist or nurse. This includes any possible side effects not listed in this leaflet. See section 4.

What is in this leaflet

1. What Xultophy is and what it is used for 2. What you need to know before you use Xultophy 3. How to use Xultophy 4. Possible side effects 5. How to store Xultophy 6. Contents of the pack and other information

1. What Xultophy is and what it is used for

What Xultophy is used for Xultophy is used to improve blood glucose (sugar) levels in adult patients with type 2 diabetes mellitus. You have diabetes because your body: • does not make enough insulin to control the level of sugar in your blood or • is not able to use the insulin properly.

How Xultophy works Xultophy contains two active substances that help your body control your blood sugar: • insulin degludec – a long-acting basal insulin which lowers your blood sugar levels. • liraglutide – a ‘GLP-1 analogue’ that helps your body make more insulin during meals and lowers the amount of sugar made by your body.

Xultophy and oral medicines for diabetes Xultophy is used with oral medicines for diabetes (such as metformin, pioglitazone and sulfonylurea medicines). It is prescribed when these medicines (used alone or with GLP-1 treatment or with basal insulin) are not enough to control your blood sugar levels.

If you use GLP-1 treatment You should stop your GLP-1 treatment prior to starting on Xultophy.

If you use insulin You should stop your insulin treatment prior to starting on Xultophy.

2. What you need to know before you use Xultophy

Do not use Xultophy • if you are allergic to insulin degludec or liraglutide or any of the other ingredients of this medicine (listed in section 6).

Warnings and precautions

38 Talk to your doctor, pharmacist or nurse before using Xultophy. • If you are also taking a sulfonylurea (such as glimepiride or glibenclamide), your doctor may tell you to lower your sulfonylurea dose depending on your blood sugar levels. • Do not use Xultophy if you have type 1 diabetes mellitus or if you have ‘ketoacidosis’ (a condition with a build-up of acid in the blood). • The use of Xultophy is not recommended in patients with inflammatory bowel disease or delayed gastric emptying (diabetic gastroparesis).

Be especially aware of the following when using Xultophy: • low blood sugar (hypoglycaemia) – if your blood sugar is low, follow the advice in section 4 ‘Low blood sugar (hypoglycaemia)’. • high blood sugar (hyperglycaemia) – if your blood sugar is high, follow the advice in section 4 ‘High blood sugar (hyperglycaemia)’. • Ensuring you use the right medicine – Always check the pen label before each injection to avoid accidentally confusing Xultophy with other products.

Important things to know before you use this medicine: Tell your doctor if you: • have eye problems. Fast improvements in blood sugar control may make diabetic eye problems get worse for a short time. The long-term improvements in blood sugar control may ease the eye problems. • have or have had a thyroid disease.

Important things to know while you are using this medicine: • if you have a severe stomach ache which does not go away, tell your doctor – this could be a sign of inflamed pancreas (acute pancreatitis). • dehydration (loss of fluids from the body) can happen if you are feeling or being sick (nausea or vomiting) or have diarrhoea – it is important to drink plenty of fluids to stop dehydration.

Skin changes at the injection site The injection site should be rotated to help prevent changes to the fatty tissue under the skin, such as skin thickening, skin shrinking or lumps under the skin. The insulin may not work very well if you inject into a lumpy, shrunken or thickened area (see section 3 ‘How to use Xultophy’). Tell your doctor if you notice any skin changes at the injection site. Tell your doctor if you are currently injecting into these affected areas before you start injecting in a different area. Your doctor may tell you to check your blood sugar more closely, and to adjust your insulin or your other antidiabetic medications dose.

Children and adolescents Do not give this medicine to children or adolescents. There is no experience with Xultophy in children and adolescents under 18 years old.

Other medicines and Xultophy Tell your doctor, pharmacist or nurse if you are taking, have recently taken or might take any other medicines. Some medicines affect your blood sugar level – this may mean your Xultophy dose has to change.

Listed below are the most common medicines, which may affect your Xultophy treatment.

Your blood sugar level may fall if you take: • other medicines for diabetes (tablets or injections) • sulfonamides – for infections • anabolic steroids – such as testosterone • beta-blockers – for high blood pressure. They may make it harder to recognise the warning signs of low blood sugar (see section 4 ‘Warning signs of low blood sugar – these may come on suddenly’) • acetylsalicylic acid (and medicines called ‘salicylates’) – for pain and mild fever

39 • monoamine oxidase (MAO) inhibitors – for depression • angiotensin converting enzyme (ACE) inhibitors – for some heart problems or high blood pressure.

Your blood sugar level may rise if you take: • danazol – medicine affecting ovulation • oral contraceptives – birth control pills • thyroid hormones – for thyroid disease • growth hormone – for low levels of growth hormone • medicines called ‘glucocorticoids’ such as cortisone – for inflammation • medicines called ‘sympathomimetics’ such as epinephrine (adrenaline), salbutamol or terbutaline – for asthma • water tablets called ‘thiazides’ – for high blood pressure or if your body is holding onto too much water (water retention).

Octreotide and lanreotide – used for treatment of acromegaly (a rare illness with too much growth hormone). They may increase or decrease your blood sugar level.

Pioglitazone – tablets used for the treatment of type 2 diabetes mellitus. Some patients with long- standing type 2 diabetes mellitus and heart disease or previous stroke, who were treated with pioglitazone and insulin, experienced the development of heart failure. Inform your doctor straight away if you experience signs of heart failure such as unusual shortness of breath or rapid increase in weight or localised swelling (oedema).

Warfarin or other blood thinners – medicines used to prevent clotting of the blood. Tell your doctor if you are taking warfarin or other blood thinners as you might need to have blood tests more often to measure how thick your blood is (called ‘International Normalised Ratio’ or INR test).

Xultophy with alcohol If you drink alcohol, your need for Xultophy may change. Your blood sugar level may either rise or fall. You should therefore monitor your blood sugar level more often than usual.

Pregnancy and breast-feeding Do not use Xultophy if you are pregnant or plan to become pregnant. Tell your doctor if you are pregnant, think you might be pregnant or are planning to have a baby. It is not known if Xultophy affects the baby.

Do not use Xultophy if you are breast-feeding. It is not known if Xultophy passes into breast milk.

Driving and using machines Having low or high blood sugar can affect your ability to drive or use any tools or machines. If your blood sugar is low or high, your ability to concentrate or react might be affected. This could be dangerous to yourself or others. Ask your doctor whether you can drive if: • you often get low blood sugar • you find it hard to recognise low blood sugar.

Important information about some of the ingredients of Xultophy Xultophy contains less than 1 mmol sodium (23 mg) per dose. This means that the medicine is essentially ‘sodium-free’.

3. How to use Xultophy

Always use this medicine exactly as your doctor has told you. Check with your doctor, pharmacist or nurse if you are not sure.

If you are blind or have poor eyesight and cannot read the dose counter on the pen, do not use this pen

40 without help. Get help from a person with good eyesight who is trained to use the Xultophy pre-filled pen.

Your doctor will tell you: • how much Xultophy you will need each day • when to check your blood sugar level • how to adjust the dose.

Your dose of Xultophy is administered as ‘dose steps’. The dose counter on the pen shows the number of dose steps.

Dosing time • Use Xultophy once each day, preferably at the same time every day. Choose a time of the day that works best for you. • If it is not possible to use Xultophy at the same time every day, it can be used at a different time of the day. Make sure to have a minimum of 8 hours between the doses. • You do not have to use Xultophy with a meal. • Always follow your doctor’s advice for dose and dose adjustment. • If you want to change your usual diet, check with your doctor, pharmacist or nurse first as a change in diet may alter your need for Xultophy.

How to handle Xultophy Xultophy is a pre-filled dial-a-dose pen. • Xultophy is administered as ‘dose steps’. The dose counter on the pen shows the number of dose steps. • One dose step contains 1 unit of insulin degludec and 0.036 mg of liraglutide. • The maximum daily dose of Xultophy is 50 dose steps (50 units of insulin degludec and 1.8 mg of liraglutide). Carefully read the ‘Instructions on how to use’ on the other side of this leaflet and use the pen as described. Always check the pen label before you inject your medicine to ensure that you use the correct pen.

How to inject Before you use Xultophy for the first time, your doctor or nurse will show you how to inject. • Xultophy is given as an injection under the skin (subcutaneously). Do not inject it into a vein or muscle. • The best places to inject are the front of your thighs, upper arms or the front of your waist (abdomen). • Change the place within the area where you inject each day to reduce the risk of developing lumps and skin pitting (see section 4). • Always use a new needle for each injection. Re-use of needles may increase the risk of blocked needles leading to inaccurate dosing. Dispose of the needle safely after each use. • Do not use a syringe to remove the solution from the pen to avoid dosing errors and potential overdose.

Detailed instructions for use are on the other side of this leaflet.

Do not use Xultophy: • If the pen is damaged or has not been stored correctly (see section 5). • If the liquid you can see through the pen window does not look clear and colourless.

Use in elderly patients (65 years old or over) Xultophy can be used in elderly patients but if you are elderly you may need to check your blood sugar level more often. Talk to your doctor about changes in your dose.

If you have kidney or liver problems If you have kidney or liver problems, you may need to check your blood sugar level more often. Talk

41 to your doctor about changes in your dose.

If you use more Xultophy than you should If you use more Xultophy than you should, your blood sugar may get low (hypoglycaemia) or you may feel or be sick (nausea or vomiting). If your blood sugar gets low, see the advice in section 4 ‘Low blood sugar (hypoglycaemia)’.

If you forget to use Xultophy If you forget a dose, inject the missed dose when discovering the mistake, ensuring a minimum of 8 hours between doses. If you discover that you missed your previous dose when it is time to take your next regular scheduled dose, do not take a double dose.

If you stop using Xultophy Do not stop using Xultophy without talking to your doctor. If you stop using Xultophy this could lead to a very high blood sugar level, see the advice in section 4 ‘High blood sugar (hyperglycaemia)’.

If you have any further questions on the use of this medicine, ask your doctor, pharmacist or nurse.

4. Possible side effects

Like all medicines, this medicine can cause side effects, although not everybody gets them. The following serious side effects may happen with this medicine:

• Low blood sugar (very common: may affect more than 1 in 10 people). If your blood sugar level gets low you may pass out (become unconscious). Serious hypoglycaemia may cause brain damage and may be life-threatening. If you have signs of low blood sugar, take actions to increase your blood sugar level straight away. See advice in ‘Low blood sugar (hypoglycaemia)’ further down in this section. • Serious allergic reaction (anaphylactic reaction) (not known: frequency cannot be estimated from the available data). If you have a serious allergic reaction to any of the ingredients in Xultophy, stop using Xultophy and see a doctor straight away. The signs of a serious allergic reaction are: • local reactions spread to other parts of your body • you suddenly feel unwell with sweating • you have difficulty breathing • you get a fast heartbeat or feel dizzy.

Skin changes at the injection site: If you inject insulin at the same place, the fatty tissue may shrink (lipoatrophy) or thicken (lipohypertrophy) (may affect up to 1 in 100 people). Lumps under the skin may also be caused by build-up of a protein called amyloid (cutaneous amyloidosis; how often this occurs is not known). The insulin may not work very well if you inject into a lumpy, shrunken or thickened area. Change the injection site with each injection to help prevent these skin changes.

Other side effects include: Common (may affect up to 1 in 10 people) • Lower appetite, feeling or being sick (nausea or vomiting), diarrhoea, constipation, indigestion (dyspepsia), inflamed lining of the stomach (gastritis), stomach ache, heartburn or bloating – these usually go away after a few days or weeks. • Injection site reactions. The signs may include bruising, bleeding, pain, redness, hives, swelling or itching – these usually go away after a few days. See your doctor if they do not disappear after a few weeks. Stop using Xultophy and see a doctor straight away if they become serious. • Increase of pancreatic enzymes, such as lipase and amylase.

Uncommon (may affect up to 1 in 100 people) • Hives (red bumps on your skin that are sometimes itchy).

42 • Allergic reactions (hypersensitivity) such as rash, itching and swelling of the face. • Dehydration (loss of fluid from the body) – it is important to drink plenty of fluids to stop dehydration. • Belching (eructation) and wind (flatulence). • Rash. • Itching. • Increased heart rate. • Gallstones. • Inflamed gallbladder.

Not known (frequency cannot be estimated from the available data) • Inflamed pancreas (pancreatitis). • Swelling of arms or legs (peripheral oedema) – when you first start using your medicine, your body may keep more water than it should. This causes swelling around your ankles and other joints. This is usually only short-lasting.

General effects from diabetes treatment

► Low blood sugar (hypoglycaemia)

Low blood sugar may happen if you: • drink alcohol • exercise more than usual • eat too little or miss a meal • use too much Xultophy.

Warning signs of low blood sugar – these may come on suddenly Headache, slurred speech, fast heartbeat, cold sweat, cool pale skin, feeling sick (nausea), feeling very hungry, shaking, feeling nervous or worried, unusually tired, weak and sleepy or confused, difficulty concentrating, short-lasting changes in your sight.

What to do if you get low blood sugar: • Eat glucose tablets or another high sugar snack – like sweets, biscuits or fruit juice (always carry glucose tablets or a high sugar snack, just in case). • Measure your blood sugar if possible and rest. You may need to measure your blood sugar more than once. This is because improvement in your blood sugar may not happen straight away. • Wait until the signs of low blood sugar have gone or when your blood sugar level has settled. Then carry on with your medicine as usual.

What others need to do if you pass out: Tell everyone you spend time with that you have diabetes. Tell them what could happen if your blood sugar gets low, including the risk of passing out.

Let them know that if you pass out, they must: • turn you on your side • get medical help straight away • not give you any food or drink – because you may choke.

You may recover more quickly from passing out with an injection of glucagon. This can only be given by someone who knows how to use it. • If you are given glucagon, you will need sugar or a sugary snack as soon as you come round. • If you do not respond to a glucagon injection, you will have to be treated in a hospital. • If severe low blood sugar is not treated over time, it can cause brain damage. This can be short- or long-lasting. It may even cause death.

Talk to your doctor if: • your blood sugar got so low that you passed out

43 • you have had an injection of glucagon • you have had low blood sugar a few times recently. This is because the dosing of your Xultophy injections, food or exercise may need to be changed.

► High blood sugar (hyperglycaemia)

High blood sugar may happen if you: • drink alcohol • exercise less than usual • eat more than usual • get an infection or a fever • have not used enough Xultophy, keep using less Xultophy than you need, forget to use Xultophy or stop using Xultophy without talking to your doctor.

Warning signs of high blood sugar – these normally appear gradually Flushed, dry skin, feeling sleepy or tired, dry mouth, fruity (acetone) breath, urinating more often, feeling thirsty, losing your appetite, feeling or being sick (nausea or vomiting). These may be signs of a very serious condition called ‘ketoacidosis’. This is a build-up of acid in the blood because the body is breaking down fat instead of sugar. If not treated, this could lead to diabetic coma and eventually death.

What to do if you get high blood sugar: • Test your blood sugar level. • Test your blood or urine for ketones. • Get medical help straight away.

Reporting of side effects If you get any side effects, talk to your doctor, pharmacist or nurse. This includes any possible side effects not listed in this leaflet. You can also report side effects directly via the national reporting system listed in Appendix V. By reporting side effects you can help provide more information on the safety of this medicine.

5. How to store Xultophy

Keep this medicine out of the sight and reach of children.

Do not use this medicine after the expiry date which is stated on the pen label and carton after ‘EXP’. The expiry date refers to the last day of that month.

Before opening Store in a refrigerator (2°C to 8°C). Keep away from the freezing element. Do not freeze.

During use Do not freeze. You can carry Xultophy with you and keep it at room temperature (no more than 30°C) or in a refrigerator (2°C to 8°C) for up to 21 days. The product should be thrown away 21 days after first opening.

Always keep the cap on the pre-filled pen when you are not using it in order to protect it from light.

Do not throw away any medicines via wastewater or household waste. Ask your pharmacist how to throw away medicines you no longer use. These measures will help protect the environment.

6. Contents of the pack and other information

What Xultophy contains

44 • The active substances are insulin degludec and liraglutide. Each mL of solution contains 100 units of insulin degludec and 3.6 mg liraglutide. Each unused pre-filled pen (3 mL) contains 300 units of insulin degludec and 10.8 mg liraglutide. • The other ingredients are glycerol, phenol, zinc acetate, hydrochloric acid and sodium hydroxide (for pH adjustment), and water for injections. See also section 2 ‘Important information about some of the ingredients of Xultophy’ for information on sodium.

What Xultophy looks like and contents of the pack Xultophy is a clear and colourless solution. Pack sizes of 1, 3, 5 and a multipack containing 10 (2 packs of 5) pens of 3 mL. Not all pack sizes may be marketed.

Marketing Authorisation Holder and Manufacturer Novo Nordisk A/S Novo Allé DK-2880 Bagsværd, Denmark

Now turn over for information on how to use your pre-filled pen.

This leaflet was last revised in

Other sources of information

Detailed information on this medicine is available on the European Medicines Agency web site: http://www.ema.europa.eu.

45 Instructions on how to use Xultophy 100 units/mL + 3.6 mg/mL solution for injection

Please read these instructions carefully before using your Xultophy pre- filled pen. Do not use the pen without proper training from your doctor or nurse. Start by checking your pen to make sure that it contains Xultophy 100 units/mL + 3.6 mg/mL, then look at the illustrations below to get to know the different parts of your pen and needle.

If you are blind or have poor eyesight and cannot read the dose counter on the pen, do not use this pen without help. Get help from a person with good eyesight who is trained to use the Xultophy pre-filled pen.

Xultophy is a medicine that contains insulin degludec and liraglutide. Xultophy is administered as ‘dose steps’. One dose step contains 1 unit insulin degludec + 0.036 mg liraglutide.

Your pen is a pre-filled dial-a-dose pen. It contains 3 mL of Xultophy solution. It delivers doses from: – 1 dose step – to a maximum of 50 dose steps (50 units insulin degludec + 1.8 mg liraglutide)

Your pen delivers doses in increments of 1 dose step. Do not do any conversion of your dose. The dose steps dialled equal the number shown in the dose counter.

Your pen is designed to be used with NovoTwist or NovoFine disposable needles up to a length of 8 mm and as thin as 32G. Needles are not included in the pack.

Important information Pay special attention to these notes as they are important for safe use of the pen.

46

Xultophy pre-filled pen and needle (example)

Pen cap Outer needle cap

Inner needle cap

Needle

Paper tab

Pen scale

Pen window

Pen label

Dose counter Dose pointer Dose button Dose with selector smooth Dose surface button

1 Prepare your pen with a new needle A

• Check the name and coloured label of your pen, to make sure that it contains Xultophy. This is especially important if you take more than one type of injectable medicine. Taking the wrong medicine could be harmful to your health. • Pull off the pen cap.

47 • Check that the solution in your pen is clear and colourless. Look B through the pen window. If the solution looks cloudy, do not use the pen.

• Take a new needle, and tear off the paper tab. C

• Push the needle straight onto the pen. Turn until it is on tight. D

• Pull off the outer needle cap and keep it for later. You will need it E after the injection, to safely remove the needle from the pen.

• Pull off the inner needle cap and throw it away. If you try to put it F back on, you may accidentally stick yourself with the needle. A drop of solution may appear at the needle tip. This is normal, but you must still check the flow. Do not attach a new needle to your pen until you are ready to take your injection.

Always use a new needle for each injection. This may prevent blocked needles, contamination, infection and inaccurate dosing. Never use a bent or damaged needle.

2 Check the flow A

• Turn the dose selector to select 2 dose steps. Make sure the dose counter shows 2. • The dose counter and the dose pointer show how many dose steps of Xultophy you select.

2 dose steps selected

48 • Hold the pen with the needle pointing up. B Tap the top of the pen gently a few times to let any air bubbles rise to the top.

• Press and hold in the dose button until the dose counter returns to 0. C The 0 must line up with the dose pointer. A drop of solution should appear at the needle tip.

A small drop may remain at the needle tip, but it will not be injected. If no drop appears, repeat steps 2A to 2C up to 6 times. If there is still no drop, change the needle and repeat steps 2A to 2C once more. If a drop of solution still does not appear, dispose of the pen and use a new one.

Always make sure that a drop appears at the needle tip before you inject. This makes sure that the solution flows. If no drop appears, you will not inject any medicine, even though the dose counter may move. This may indicate a blocked or damaged needle.

It is important always to check the flow before you inject. If you do not check the flow, you may get too little medicine, or no medicine at all. This may lead to high blood sugar level.

3 Select your dose A

• Turn the dose selector to select the dose you need. The dose counter shows the dose in dose steps. If you select a wrong dose, you can turn the dose selector forward or backward to the correct dose. The pen can dial up to a maximum of 50 dose steps. The dose selector changes the number of dose steps. Examples Only the dose counter and dose pointer will show how many dose steps 5 you select per dose. dose steps You can select up to 50 dose steps per dose. When your pen contains selected less than 50 dose steps, the dose counter stops at the number of dose steps left. The dose selector clicks differently when turned forward, backward or 24 past the number of dose steps left. Do not count the pen clicks. dose steps selected

Always use the dose counter and the dose pointer to see how many dose steps you have selected before injecting the medicine. Do not count the pen clicks. If you select and inject the wrong dose, your blood sugar level may get high or low. Do not use the pen scale, it only shows approximately how much solution is left in your pen.

49 How much solution is left? A

• The pen scale shows you approximately how much solution is left in Approx. your pen. how much solution is left

• To see precisely how much solution is left, use the dose counter: B Turn the dose selector until the dose counter stops. If it shows 50, at least 50 dose steps are left in your pen. If it shows less than 50, the number shown is the number of dose steps left in your pen.

• If you need more medicine than what is left in your pen, you can split Example your dose between two pens. Dose counter Be very careful to calculate correctly if splitting your dose. stopped: 42 dose steps If in doubt, take the full dose with a new pen. If you split the dose left wrongly, you will inject too little or too much medicine. This may make your blood sugar level high or low.

4 Inject your dose A

• Insert the needle into your skin as your doctor or nurse has shown you. • Make sure you can see the dose counter. Do not cover it with your fingers. This could interrupt the injection.

• Press and hold down the dose button until the dose counter shows 0. B The 0 must line up with the dose pointer. You may then hear or feel a click.

• Keep the needle in your skin after the dose counter has returned to 0 C Count slowly: and count slowly to 6. • If the needle is removed earlier, you may see a stream of solution 1-2-3-4-5-6 coming from the needle tip. If so, the full dose will not be delivered, and you should increase the frequency of checking your blood sugar level.

50 • Remove the needle from your skin. D If blood appears at the injection site, press lightly. Do not rub the area.

You may see a drop of solution at the needle tip after injecting. This is normal and does not affect your dose.

Always watch the dose counter to know how many dose steps you inject. Hold the dose button down until the dose counter shows 0. If the dose counter does not return to 0, the full dose has not been delivered, which may lead to high blood sugar level.

How to identify a blocked or damaged needle? • If 0 does not appear in the dose counter after continuously pressing the dose button, you may have used a blocked or damaged needle. • In this case - you have not received any medicine - even though the dose counter has moved from the original dose that you have set. How to handle a blocked needle? Change the needle as described in section 5 and repeat all steps starting with section 1: Prepare your pen with a new needle. Make sure you select the full dose you need. Never touch the dose counter when you inject. This can interrupt the injection.

5 After your injection A

• Lead the needle tip into the outer needle cap on a flat surface without touching the needle or the outer cap.

• Once the needle is covered, carefully push the outer needle cap B completely on. • Unscrew the needle and dispose of it carefully as instructed by your doctor or nurse.

• Put the pen cap on your pen after each use to protect the solution from C light.

Always dispose of the needle after each injection to ensure the use of a sharp needle and prevent blocked needles. If the needle is blocked, you will not inject any medicine. When the pen is empty, throw it away without a needle on as instructed by your doctor, nurse, pharmacist or local authorities.

Never try to put the inner needle cap back on the needle. You may stick yourself with the needle. Always remove the needle from your pen after each injection. This may prevent blocked needles, contamination, infection, leakage of solution and inaccurate dosing.

51 Further important information

• Always keep an extra pen and new needles, in case of loss or damage. • Always keep your pen and needles out of sight and reach of others, especially children. • Never share your pen with other people. Your medicine might be harmful to their health. • Never share your needles with other people. It might lead to cross- infection. • Caregivers must be very careful when handling used needles – to prevent needle injury and cross-infection.

Caring for your pen

• Do not leave the pen in a car or other place where it can get too hot or too cold. • Do not store your pen at temperatures above 30°C. • Do not expose your pen to dust, dirt or liquid. • Do not wash, soak or lubricate your pen. If necessary, clean it with mild detergent on a moistened cloth. • Do not drop your pen or knock it against hard surfaces. If you drop it or suspect a problem, attach a new needle and check the flow before you inject. • Do not try to refill your pen. Once empty, it must be disposed of. • Do not try to repair your pen or pull it apart.

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